* Client First Name:
The First Name field is required.
HP_GEGEH:
* Client Last Name:
The Last Name field is required.
* Client DOB:
The Client DOB is required.
* Safe Phone Number:
The Safe Phone Number field is required.
Client Email (Optional):
* Primary Language Spoken:
The Primary Language field is required.
* Name of abuser:
The Person Being Referred field is required.
*Please note, when providing WCET with a “safe number” that means that you have spoken with this client, verified that it is a safe number, verified that it is safe to leave a voicemail, and verified that it is safe for a WCET employee to identify
* Worker's First Name:
The Workers First Name field is required.
* Worker's Last Name:
The Workers Last Name field is required.
* Worker's Email:
The Workers Email field is required.
* Worker's Phone Number:
The Workers Phone Number field is required.
* Worker's Current Supervisor:
The Workers Supervisor field is required.
Other Agency Services
* Has the client expressed interest in any of these services? These services are voluntary and cannot be mandatory:
Caseworkers: Please answer ALL of the following. Note the NO SPACE on this referral form can be left blank if you want your client to receive services from WCET. Please double check the form for accuracy and conflicting information prior to sending, as this delays the time that WCET can help connect your client to services.
If the Department’s primary involvement is NOT due to domestic violence however DV is a concern, what is the reason for primary involvement?
If you have checked any of the above boxes, please provide detailed information here.
If you have not checked any of the above boxes this client is not appropriate for services, including the ADVANCE Program.
If no, when was the last physically violent incident?
If you are concerned this client is not safe, please call the WCET crisis line at (800) 441-5555 immediately, and DO NOT rely on this referral as a means to create immediate safety for your client.
If you've marked ''no'' Please explain why a Domestic Violence Safety Plan has not been completed:
* What restrictions has The Department put in place to ensure child safety (Safety Plan/PCSP), and what are the terms of those restrictions?:
Protective Order Information
* If yes, select the type of Protective Order this client currently has:
None
Emergency Protective Order
Temporary Protective Order
Final Protective Order
The State field is required.
* If the client has an Emergency Protective Order, what is the expiration date of the Emergency Protective Order?
The Expiration Date is required.
Other Victimization History
If no, please explain:
* Per the SDM tool, what are the current danger indicators and/or risk factors The Department has identified regarding this client and the family?
Current danger indicators are required.
